Skin integrity is important

1. Determine client's risk for skin breakdown using a risk assessment tool (e.g.
Knoll Assessment Tool, Braden Scale, Gosnell Scale).
2. Inspect the skin, especially bony prominences and dependent areas, for
pallor, redness, and breakdown.
3. Implement measures to prevent tissue breakdown:
A. assist client to turn at least every 2 hours unless contraindicated
B. position client properly; use pressure-reducing or pressure-relieving
devices (e.g. pillows, gel or foam cushions, alternating pressure
mattress, air-fluidized bed, kinetic bed) if indicated
C. gently massage around reddened areas at least every 2 hours
D. apply a thin layer of a dry lubricant such as powder or cornstarch to
bottom sheet or skin and to opposing skin surfaces (e.g. axillae,
beneath breasts) if indicated to reduce friction
E. lift and move client carefully using a turn sheet and adequate
assistance
F. perform actions to keep client from sliding down in bed (e.g. gatch
knees slightly when head of bed is elevated 30 or higher) in order to
reduce the risk of skin surface abrasion and shearing
G. instruct or assist client to shift weight at least every 30 minutes
H. keep client's skin clean
I.

thoroughly dry skin after bathing and as often as needed, paying

special attention to skin folds and opposing skin surfaces (e.g. axillae,
perineum, beneath breasts); pat skin dry rather than rub

J. keep bed linens dry and wrinkle-free

K. ensure that external devices such as braces, casts, and restraints are
applied properly
L. protect the skin from contact with urine and feces (e.g. keep perineal
area clean and dry, apply a protective ointment or cream to perineal
area)
M. perform actions to prevent drying of the skin:
I.

encourage a fluid intake of 2500 ml/day unless contraindicated

II.
III.

provide a mild soap for bathing

apply moisturizing lotion and/or emollient to skin at least once
a day

N. apply a protective covering such as a hydrocolloid or transparent

membrane dressing to areas of the skin susceptible to breakdown (e.g.
coccyx, heels, elbows)
O. perform actions to maintain an adequate nutritional status (see
Diagnosis 3, action c)
P. if edema is present:
I.

perform actions to reduce fluid accumulation in dependent

areas:
a. instruct client in and assist with range of motion
exercises
b. elevate affected extremities whenever possible

II.

handle edematous areas carefully

Q. increase activity as allowed.

4. If tissue breakdown occurs:
A. notify appropriate health care provider (e.g. physician, wound care
specialist)
B. perform care of involved areas as ordered or per standard hospital
procedure.